r/HealthInsurance • u/Intelligent-Mud7047 • Apr 27 '25
Individual/Marketplace Insurance Charged extra $200.00 for one word anserr
I went to annual physical. Dr. asked me how my headaches were. My reply “Better”. I received an extra charge for office visit for $200.00. Am I suppose to refuse to answer questions during annual exams?
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u/tealestblue Apr 27 '25
I’m a medical coder and code annual wellness visits all day long. If the provider legitimately only asked how your headaches were and you said “better” and nothing else was done (labs, meds) - I absolutely wouldn’t add on an office visit.
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u/glitteringdreamer Apr 27 '25
Why is this a thing now? Did something change, or has it always been this way, but nobody billed for it?
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u/Santasreject Apr 27 '25
I really don’t get it. At my physicals my doc and I run through my conditions and how things have changed, he has never billed me for extra visits. Granted I have a good doc and he isn’t working for some big mega practice.
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u/alltheblarmyfiddlest Apr 29 '25
I got charged $25 for the mental health questions they ask.
It's so stupid.
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u/dinnerandamoviex Apr 29 '25
I was charged $140 for answering their assessment questions like a depressed person. That bill really helped my depression!
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u/tealestblue Apr 27 '25
Some practices are just shady. But also sometimes people just mess up.
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u/fantaceereddit Apr 28 '25
It’s probably not the doctor’s practice itself, rather the medical group that ‘owns’ them. They are the greedy ones that force their doctors to have so many appointments, limit the time they spend with you, and order unnecessary tests.
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u/Ridgewoodgal Apr 28 '25
My last visit I was told specifically this was an annual visit and not the “time to discuss a lot of my health issues.” lol I would think it would be the time to at least mention I am in pain, etc but nope. It’s billed a certain way so it’s seems to be all about that.
I also made an appt for my knee and I said to the medical assistant who saw me first that I wanted to mention that my bladder condition is worse. She said that I might need to make another appt for that. This is at a new doctor for me and my old one never does that so I don’t know why it’s still ok for him to discuss all my health issues. I assumed it was all due to insurance but maybe someone can weigh in on this.
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u/flybyme03 Apr 29 '25
Yes this is what my Dr told me. Makes sense and should streamline appointments and help with referrals
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u/Pushmehbutton Apr 29 '25 edited Jun 16 '25
It's about greedy doctors. I recently had a doctor who would only see you for one issue at a time no matter how small the issue was if you asked another question he would tell you that you have to book another Appointment. Finally switched back to my old doctor who left that place and he will listen to what you have to say if you ask a few things no big deal.
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u/Ridgewoodgal Apr 29 '25
I totally get that because I definitely prefer my old doctor for same reason. He actually asks if I have any other issues or concerns. The new doctor is at a very large practice associated with a teaching hospital. I really like that they have all the specialists in one place but for my GP I am going to drive a bit further to my original doc.
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u/JediSnoopy Apr 28 '25
Yes, an annual routine exam is billed differently from an exam in which non-preventative care health issues are discussed. This is why you should be careful about discussing anything not connected to your preventative care exam. Diagnostic tests, for example, are billed differently than routine tests which could result in an extra charge for you.
In the case of the OP, it would appear that during the annual exam, the doctor asked about a medical issue that didn't fall under preventative care and then billed the insurance company for it.
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u/flybyme03 Apr 29 '25
People don't like this answer but it is the correct answer. It's all business. Back to using ERs
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u/Ridgewoodgal Apr 29 '25
On one hand I get that they want to focus on a physical but tbh not all docs even do a true physical anymore besides BP, temperature and listening to your heart. I remember before docs doing a full body exam. They’d listen to bowel sounds. Press on your stomach, lift your legs up and down etc. That really doesn’t happen at docs I see for annual physical.
It’s funny because I was talking to my friend about how so many docs, even specialists, don’t seem to want to touch you. lol They will listen to your issues but I wish they would actually touch the areas and find out what is going on. For example, I have two autoimmune issues and the PA I see at Rheumatologist office never actually physically exams my joints. It’s all just visual. Not saying all are like this but a lot are. My friend has same experience.
We also never hardly ever see an actual doctor. My GP provider is a PA and I have not seen the doctor he works under for 20 years. At some practices I have never seen a doctor. Luckily, for the more advanced specialists I see, I do get to see the MD/DO, but it seems like that is the exception not the rule. Clearly there are not enough doctors.
I live in LA area in California and my friend is in Ohio and her experience is the same so it isn’t just large metro areas.
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u/Forward-Ad5509 Apr 30 '25
Exactly, annual visits can be billed with office visits given the doctor is documenting throughly the need for both as well as diagnosis on each charge reflect that.
It is not unusual to do this, most medical billers are aware of this but non-medical Biller wouldn't know.
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u/PsychoCelloChica Apr 28 '25
Private equity sticking their fingers into health care. Physicians are no longer salaried employees, or small practice owners. Now they are employed by companies trying to squeeze every ounce of productivity and cash flow out of them. They often get paid based on ‘Relative value Units’. Instead of charging for a flat rate for their services, it’s all about how many billing codes they can justify for each appointment. Every code increases the bill.
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u/flybyme03 Apr 29 '25
Meanwhile you as the patient get worse and less care for the money. I left medicine early for a reason.
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u/PsychoCelloChica Apr 29 '25
I just wished primary care in my area still actually treated things in office. In 8 years, the only things I haven’t been referred to a specialist for are my annual albuterol inhaler refill, and when I needed a note for work for Covid. Oh, and the annual lecture about my weight, of course.
I honestly got so tired of wasting my leave and paying double copays that I now just skip my primary and book with the specialist or got to an urgent care or CVS clinic. My PCP wouldn’t even discuss writing something for depression/anxiety, she refered me out to psych. That was a whole other saga.
But even that was better than my previous doc who just said “You American women are too high strung. If you just took care of your husbands and babies, ate less, and exercised 45 minutes a day, you wouldn’t all be so anxious.” (Even more offensive as she knew I was childfree and married to another woman.)
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u/rdizzy1223 Apr 27 '25
Because insurance companies are shit, and they usually allow free yearly check ups, and they don't want doctors or patients giving/getting a sliver of treatment for free.
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u/Sad-Contract9994 Apr 27 '25
No, it costs insurance companies money when a doctor bills higher costs. The annual wellness that’s covered for free is paid for (in one way or another) by the insurance. Why would they want to pay more?
Billing for a more expensive visit gets the doctor money at the cost of both you and your insurance.
I suspect that in-network doctors have an arrangement that gets them very little pay for those annual exams.
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u/Highstakeshealthcare Apr 27 '25
In network discounts are smoke and mirrors. Cash is mostly always better. I know insurance pays for wellness at 100% (the parts they approve anyway). I just had my annual exam. I pay cash for everything because I refuse to participate in their games.
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u/Sad-Contract9994 Apr 27 '25
Well, often it is true that you can get a better cash rate than the in-network allowable amount. But, generally once you’ve met your deductible, it’s different. You would be hard pressed to get an in-person appointment at a doctors office for $50 cash pay.
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u/Highstakeshealthcare Apr 27 '25
I look at deductibles differently than most. I add monthly premium to the deductible. IF I decided to play their games, my premium would be $1200/month ($14,400 year). Without that premium there would be no deductible. The deductible for that plan was $3500 so I’d have to pay a total of $17,900 to get an office visit copay for $50. I have a plan for any major event but I like my money in the bank where I can use it the way I want.
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u/Sad-Contract9994 Apr 27 '25
Sure, if you’re gonna go without health insurance altogether, this calculation around office visits does make sense. Especially at that premium 😳
My annual in-network out of pocket max is $3500, and deductible is $1700.
So even if my premiums were as high as yours, my annual healthcare spend would be a min of $16,000 (I always bit the deductible) and a max of $18,000 (all rounded numbers.)
So, if I needed zero healthcare, and saved that $18k a year (say) and got a decent interest rate for a decade, I could have $220,000. A pretty nice sum. Now, my mom had leukemia and her insurance-billed treatment for a 14 day hospital stay was about $200,000. 20 years ago. Assume you could negotiate to half.
So, assuming all of that, if you were lucky enough to need no medical treatment for that time, and got a good interest rate, but then unlucky enough to get cancer, you might still have around a hundred grand. Of course, if would be less if you had cancer and survived and needed a lot more treatment. Also, this doesn’t take into account rising premium costs AND medical costs AND inflation and lowering spending power of the dollar.
On the OTHER hand, once you do get cancer, you won’t be able to work, and so, you won’t be able to keep paying those premiums, so all that money for coverage will be in the trash.
So yea, it seems like a personal choice for everyone to roll the dice on.
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u/Highstakeshealthcare Apr 27 '25
I understand all the options and it is personal choice but hospitals like HCA give a 92% discount to uninsured regardless of income. I’ve been in this industry for over 30 years from all sides of it and there is just nothing good about it. It’s sad and it causes financial ruin for so many.
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u/Sad-Contract9994 Apr 27 '25 edited Apr 27 '25
I hear you but there is no way people get 92% discounts on the regular uninsured. The uninsured, who cannot show financial resources, also have trouble getting treatment. If you’ve been in the industry for 30 years and are gonna tell me that you can walk into a good oncologist with no insurance and expect to pay 10% of their customary, I’m gonna need to make some calls to some and pretend not to have insurance to check that out. — I’d also like to play a game called, how far out will they book me when I tell them I’m cash pay and going to need a discount.
My mother, when she was pregnant with my sister, needed a life flight and my sister was in the NICU. At one point they wheeled her down, while she was still admitted, to negotiate with a really nasty and threatening billing department. She was hounded for a long time with bills. The calls, the letters, trying to get those discounts— she did NOT get 90% off. (Yep, mom was really unlucky.)
But we agree: it’s sad, there’s nothing good about any of the options, and the choice is personal.
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u/JediSnoopy Apr 28 '25
The doctor's office billed the insurance company when the OP answered a question that the office itself asked. I don't think the problem is the insurance company here.
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u/rdizzy1223 Apr 28 '25
Yes, because insurance companies have ridiculously restrictive defining characteristics of what a yearly exam is, and they make these free. Most of these are nearly impossible to meet. The doctors office cannot legally lie to the insurance companies about what happened during the appointment
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u/flybyme03 Apr 28 '25
They are going after people who are only there for free annu visit and end up getting a bunch of other things added on that aren't covered. My gyros office had me terrified to even answer question about my period because if it wasn't regular then that would count as a separate thing. Doctor calmed me down and explained
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u/glitteringdreamer Apr 29 '25
How is my annual visit not the exact right time to cover a bunch of things that might be of concern?
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u/flybyme03 Apr 30 '25
it used to be and you used to have the same doctor, but now no one wants to be a pcp
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u/Intelligent-Mud7047 4d ago
I appealed and got it dropped. The insurance company said it’s called medication review so it’s diagnostic. There was no change in medication or labs order or tests so finally got the Dr to drop charges.
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u/TelevisionKnown8463 Apr 27 '25
This whole system sucks. I think if you want to avoid being billed for anything but the preventative exam you could try making that clear when you schedule the exam. And then if asked a question, say “I am just here for a preventative exam; I can’t afford the fees for anything else. please just do an annual screening exam. I’ll schedule a separate visit to discuss my existing issues.” Then don’t schedule the follow-up unless you need it.
In our current world of crappy insurance reimbursements, I get why providers want to maximize. This will matter more to some patients than others. Currently I have a highish deductible plan with very low coinsurance after I meet the deductible, and I always meet the deductible early in the year, so I don’t really mind if my provider does things to jack up what they can charge a bit. It sounds like you’re in a different situation, but your providers don’t know that.
So I would try being transparent with them that you want to keep costs down. If they don’t work with you on that, find a new provider.
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u/Intelligent-Mud7047 Apr 27 '25
I will refuse to answer questions in future
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u/Dee__Greg Apr 27 '25
It’s insane if we need to start treating doctors visits as traffic stops.
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u/owlears1987 Apr 27 '25
But it’s not insane to start putting some responsibility on providers to understand that asking a simple question and then noting it a certain way costs us. My impression is that they are often ignorant of exactly how expensive some of their actions are and they really shouldn’t be.
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u/runwith Apr 28 '25
I don't think they are ignorant of it. In general they tend to be underpaid by insurance and will bill them as much as they can
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u/bluedonutwsprinkles Apr 27 '25
The Dr could refuse to refill meds without an office visit.
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u/joltdude May 08 '25
They do and I’m talking for routine maintenance meds. I call it “prescription extortion”…. I.e insulin for examples
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u/TelevisionKnown8463 Apr 27 '25
Definitely. They also could say “sorry, if I have a patient under my care who has a condition, I can’t see them and not pay attention to how the condition/treatment is going.” But I don’t think all doctors would do either of these things. When I was a kid my primary care doctor routinely refilled my asthma meds, no need for a visit.
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u/Drused2 Apr 27 '25
As they should. If the patient doesn’t want an office visit, they don’t get an office visit.
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u/Blackpaw8825 Apr 27 '25
The issue here is that OP went for their annual which should've been $0 out of pocket, but because it turned into a follow up because of a single unprompted question they billed it as a visit (I'm assuming 99214 given the $200).
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u/Sad-Contract9994 Apr 27 '25
There is little point is trying to converse with someone who talks like that.
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u/Starbuck522 Apr 27 '25
Did you ask the office if a mistake was made? Maybe they will change it.
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u/Intelligent-Mud7047 Apr 27 '25
I called the billing dept. I was told if I have a diagnosis, then it’s automatically an office visit. I take meds for headaches and high blood pressure. I asked her then I was charged for an office visit before I walked in the door for diagnosis. She said correct.
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u/Saturngirl2021 Apr 27 '25
Doctors office knows that it was only a wellness check and should not have added any other diagnostic codes for billing. I would call them and ask to speak to the doctor’s nurse. Ask why they added the code for that. You can also call the insurance company and appeal stating was annual wellness check only. They should remove the code for that.
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u/Intelligent-Mud7047 Apr 27 '25
They stated that dr asked how headache was and me replying better was considered Medication Review and is billable as office visit. They said it shoukd not have happened during annual physical but they are allowed.
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u/wolfofone Apr 27 '25
So they will be refilling all your meds for the rest of the year without having to come back in then right? If you can't get them to back down on the office visit charge make sure you get your $200 worth out of them lol.
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u/Foreign_Afternoon_49 Apr 27 '25
I second that OP might win if appealing directly through their insurance.
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u/taytrippin Apr 27 '25
I dont believe insurance will care. They can request records but can’t do much just because OP doesn’t feel it was fair.
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u/Foreign_Afternoon_49 Apr 27 '25
I have successfully appealed a similar case where my annual preventive visit was coded as an office visit. My insurance re-processed the claim as preventive.
OP, just explain what happened in your appeal narrative as you did here: that you didn't raise any concerns, that you only answered the doctor's question with "better", and that no treatment plan was discussed.
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u/taytrippin Apr 27 '25
If it’s a self funded plan, they really don’t care. I’m glad it worked for you, and it’s worth trying, but I work for a health insurance company that is self funded and they don’t care.
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u/larue555 Apr 27 '25
I would contest the billing that no treatment or discussion happened. I had this happen in the past and billing had coding review the doctor's notes. They removed the charge. The claim has to have a specific modifier on it to prevent insurance from rolling the office visit code into the well visit code.
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Apr 27 '25
[deleted]
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u/aredubblebubble Apr 27 '25
Not $200 for 5 secs of talking.
$200 for years of medical training and experience to ask "How is your headache?" and then the expert knowledge to know how to guide the patient upon learning that he is "better."
Probly threw in a nod and slight smile for free, OP is lucky.
/S
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u/Kubya_Dubya Apr 27 '25
Hey I have nearly 400k of loans., that’s basically an invisible house. They gotta get paid back 1 $200 brick at a time lol
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u/art4z Apr 27 '25
Enshittification has hit medicine. Pressure on doctors to turnover a certain number of patients and produce profits has led to terrible degradation in the field as it historically existed. https://en.m.wikipedia.org/wiki/Enshittification
So yes, going forward, if your doctor ask you a question, ask them if this question is within the scope of the annual physical, and refuse to answer if not. There are doctors who are looking to upcode visits, and feel very righteous about doing so.
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u/Soggy-Pen-2460 Apr 27 '25
Definitely need to bring your lawyer with you to a medical visit. Doctors will need to ‘mirandize’ their patients
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u/gronwallsinequality Apr 27 '25
and feel very righteous about doing so.
They make dishonest mechanics look good.
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u/Comfortable-Cash-403 Apr 27 '25
It sounds like the coding and billing department is not clear on the requirements and is adding a problem focused evaluation and management code to your claim because the provider addressed the word headache. This is both a misinterpretation of coding guidelines and the ACA.
The actual law states, 45 CFR § 147.130(a)(2) - "Coverage of preventive health services"
"(2) Office visits. (i) If an item or service described in paragraph (a)(1) of this section is billed separately (or is tracked as individual encounter data separately) from an office visit, then a plan or issuer may impose cost-sharing requirements with respect to the office visit. (ii) If an item or service described in paragraph (a)(1) of this section is not billed separately (or is not tracked as individual encounter data separately) from an office visit and the primary purpose of the office visit is the delivery of such an item or service, then a plan or issuer may not impose cost-sharing requirements with respect to the office visit. (iii) If an item or service described in paragraph (a)(1) of this section is not billed separately (or is not tracked as individual encounter data separately) from an office visit and the primary purpose of the office visit is not the delivery of such an item or service, then a plan or issuer may impose cost-sharing requirements with respect to the office visit."
This provision specifically addresses when an office visit must be covered without cost-sharing based on whether the "primary purpose" of the visit is for preventive services. When the primary purpose is preventive care, the entire office visit must be provided without cost-sharing.
OP stated that this was an exchange plan, so this is the relevant citation.
In terms of coding guidance and requirements, the additional time and work for a provider to assess and treat a problem is separate from the preventive health visit. It sounds like this was not a separate assessment or medical decision making regarding medication management, just a casual mention.
In this case, it sounds like the medical coders here are just looking at the diagnosis of headache and saying the visit is problem focused and that qualified as a separate visit. If you scheduled a preventive visit with your provider and went in with the expectation that it was preventive, it is up to the provider to inform you if they are starting what is called a separately identifiable service and allow you to consent. In my experience, most providers feel it impacts the provider patient relationship to have this conversation in an exam room, but it really is their responsibility. I'd either formally request a billing review with your physician, and/or request an amendment to your medical record (which they are legally required to respond to). If they remove the diagnosis from the documentation, then request a corrected claim be sent.
It sounds super frustrating! When I received appeals like this where the patient was surprised by the extra charge, I looked at how the visit was scheduled and asked the provider if they got patient consent to start a problem focused visit if the intention of the visit was preventive. If they said no, I corrected the claim and removed the charge. There's a lot of practices out there who do train their providers to both provide great care and understand that part of providing great care is providing enough information to the patient to make an informed consumer decision about what they are getting. These rules really exist for those patients who come into their preventive visit and want to discuss 20 problems and spend two hours with the provider. This type of billing has a time and place, but it isn't automatic based on any mention of a problem.
Best of Luck!
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u/Intelligent-Mud7047 Apr 27 '25
Thank you. No they didnt get consent. Unfortunately, in the future. I will firmly state I’m here for a preventative and will state to the dr that I will not answer any questions at all. I will appeal this.
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u/Ok_Conflict1028 Apr 28 '25
So, in all sincerity…what is the point of the screening being free? That I get 100% off If they find nothing? That doesn’t help much if you’re already leery of the costs if something IS wrong, Y’know? If just discussing problems can get additional bills then as we see in the thread, you’re disincentived to actually discuss your problems.
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u/Fun-Weight-8899 Apr 27 '25 edited Apr 27 '25
This is insanity. Two years ago, I discovered direct care medicine (AKA “concierge” care). I have access to same day appointments for whatever/whenever. I can call email my physician or his PA with whatever needs I may have from annual physicials to skin tags. I pay a monthly fee. A few months ago, I had a UTI which I confirmed with an at home test. In one phone call, I had antibiotics prescribed on the same day with no fuss and no muss. If I had used insurance, it would have been a high priced visit to an emergency care because the soonest my primary care would have gotten me in would have been a couple of weeks out. I do keep my employer insurance plan for any caatastrophic/huge/hospitalizations. I just cannot imagine seeing someone I entrust my health to and not being able to ask or answer a question about any aspect of it. I hate insurance driven healthcare.
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u/joltdude Apr 27 '25
Direct care is still for the privileged unfortunately
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u/joltdude Apr 27 '25
Places around here still want a 1k or higher deposit I know there’s some affordable direct care practices but not locally .. it’s still a privilege for many and actually have lost access to some of my doctors over this but I understand their concerns as well .
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u/Fun-Weight-8899 Apr 27 '25
I would not consider myself privileged economically—I make a fair salary in the upper 5 figures. I gave up my morning designer coffee which was adding up quickly at $6 a day—or $120 a month minimum to pay for my $100 per month direct care fee. When I started investigating, I assumed that direct care was out of my range as well. As it turned out, it was not. It may be more of an option than many people think.
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u/Stay_Scientific Apr 27 '25
A few years ago my partner visited a doctor that did something similar. He went in for a yearly physical, which should have cost nothing. During the visit, the doc asked if he was interested in quitting smoking, my partner said no. Then they billed for a "problem visit" instead of an annual because of that conversation. We tried to dispute it with the doctor's office and our insurance company and it got us nowhere. He just never went back to that doctor again.
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u/HopefulCat3558 Apr 27 '25
How can a doctor perform a physical exam without asking about all of your health conditions?
I guess I should consider myself very lucky that my annual physical exam is covered 100% despite having diabetes (which my primary GP monitors, does the bloodwork for and prescribes medication), asks me about my migraines which I’m under the care of a neurologist for, and will prescribe medication and/or refer me to another specialist when I raise other concerns during the exam.
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u/SDRAIN2020 Apr 27 '25
We learned the hard way not to ask any additional questions that do not pertain to our annual physical. Husband mentioned his wrist hurt and she said he should see an orthopedic doctor. Then billed us $250 for a consultation. It sucks.
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u/Fit-Story-1331 Apr 27 '25
That happened to me. My doctor called me from an 800 number and asked me a few questions. I was billed $200 for the call from my insurance. I was surprised when I got the bill. I paid the copay and called it a day.
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u/bonitaruth Apr 27 '25
That’s ironic. Usually a doctor will say during a well woman exam that they can’t discuss other health issues as that requires another appointment.
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u/Intelligent-Mud7047 Apr 27 '25
Insurance company stated this is called “Medication Review” to see how my medication is working and it is billable. They stated, I should have been informed it’s billable. I guess I can refuse to answer and risk them dropping my medication.
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u/Fantastic-Arm-1188 Apr 27 '25
I highly doubt you were charged $200 for answering a question. Sounds like you were charged for the visit.
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u/Elyrana Apr 27 '25
What they probably mean is that by discussing the headaches the visit no longer fit the annual physical criteria and was coded as a sick or follow up visit. OP was probably expecting the physical to be covered 100% as a preventative care appointment.
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u/Intelligent-Mud7047 Apr 27 '25
Answering better is not a discussion.
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u/Elyrana Apr 27 '25
Oh I agree with you 100%. But from the insurance companies’ perspectives anything outside their definition of an annual wellness visit is discussing new issues. I was just trying to explain to the other commenter why you were indeed charged for answering a question.
You should call and talk to the practice manager since you weren’t the one to bring it up though.
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u/Fantastic-Arm-1188 Apr 27 '25
Every time I have a physical, it usually consists of the office visit and then bloodwork. I’ve always brought up other issues while I’m there and still only just paid for the office visit plus whatever was not covered on the blood work.
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u/Causerae Apr 27 '25
That's a common mistake on the provider's part and is changing in many practices
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u/Intelligent-Mud7047 Apr 27 '25
Not a mistake. Insurance company stated it’s called Medication Review and it’s billable. I called office manager. She stated any patien with a diagnosis is automatically charged for an office visit. I asked, so I was charged before I even walked in the door. Her response, correct.
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Apr 27 '25
I was charged for a physical during my annual wellness exam because I called it a "physical". I didn't know any better and thought they were the same thing. You literally have to say "wellness exam", at least thats how it was explained to me.
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u/Silent_Cookie9196 Apr 27 '25
I would consider changing doctors if this is how that practice/its billing department operates.
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Apr 27 '25
[deleted]
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u/Turbulent-Pay1150 Apr 27 '25
Insurance did not decide this. Regulations say well visits are covered. Your questions aren’t but insurance didn’t make the rule. They are following it nothing more. They pay for what the doctor codes on the bill.
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u/NotTheGreatNate Apr 27 '25
Agreed, there's nothing forcing a physician/their office to include codes for basic health questions you ask your PCP - the Physician is allowed to, which is very different. I think it's crazy, and a bad practice, to disincentivize people from asking health questions during a wellness exam, as that helps enable nipping issues in the bud and preventing them from escalating.
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u/Resident_Birthday671 Apr 27 '25
A lot of people do and unfortunately, if the insurance company thinks it's outside of the scoop of wellness they will bill you for it. I had to learn that the hard way.
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u/treble-maker123 Apr 27 '25
I've had this happen to me as well. During an annual check-up the doctor asked me about my allergies, and provided me with some medication I could take. The hospital then charged me for an office visit - I called in later and was told that because of that discussion, it was no longer an annual physical. This was at the height of COVID so it was just a phone call/telehealth, which was wild to me. I moved to a new place at that time and was looking for a new primary care doctor. Needless to say, I stayed away from that hospital group.
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u/Nervous-Row6723 Apr 27 '25
That's ridiculous, medication review should be standard for a wellness visit.
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u/vwaldoguy Apr 27 '25
I think this is a way doctors upcharge without upselling anything. They get to double bill for an annual physical and a routine office visit. And yes, I know it's allowed. But that doesn't mean I like it.
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u/ButterscotchIll1523 Apr 27 '25
When I went with my daughter to her first OBGYN appointment they asked her to fill out a mental health form. (She was a teen). The doctor looked at it and said it looks good. They billed us 300$ for a mental health evaluation. I fought it, the doctor agreed it wasn’t a mental health visit and let billing know. It took a few months to be worked out.
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u/Doge-of-WallStreet Apr 29 '25
You can ask them for an itemized bill. Sometimes, they put random things to charge you a lot
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u/Apprehensive-Crow-94 Apr 27 '25
I refuse my annual wellness visit because of this. Talk about an existing condition? extra charge. Talk about something newly discovered? Extra charge.
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u/Rockingbird256 Apr 27 '25
You can be charged extra even if you don't say anything. My BP was 2 points over their 140 number so then that became the reason for the visit.
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u/DKep0711 Apr 27 '25
You indicated in another message that you take medications for high blood pressure and headaches.
Does this doctor prescribe the medications or are they prescribed by a specialist?
2
u/spmurthy Apr 27 '25
And would you be going back to get those medications refilled for the year or would be getting it without a visit?
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u/Novel_Primary4812 Apr 27 '25
Common practice they can get away with. Call and ask for that office manager.you may get it dropped. Our healthcare system sucks.
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u/Max_Snow_98 Apr 27 '25
get away with? Do you have any what it does to a dr’s schedule when someone comes in for an annual but has a list of ailments they want to go over in addition to the basic stuff?
and people wonder why dr’s are usually behind schedule on a daily basis.
6
u/Novel_Primary4812 Apr 27 '25
You are so far off topic here. Did you even read what OP said? They answered a question and the bill was padded. It happened to my wife. Same situation. A complaint got the extra charge dropped.
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u/Max_Snow_98 Apr 27 '25
i am responding to you, not the OP. I am responding specifically to your blanket statement of what dr’s can “get away with.” You can tell by the indentation of my comment under yours.
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u/Novel_Primary4812 Apr 27 '25
You are not posting anything of use to OP. At least my post confirmed OPs experience and how to possibly correct it. I’m guessing you use that code often in your practice…
6
u/SaltyDog556 Apr 27 '25
OP didn't ask the question. Only answered. If OP doesn't ask then it is indeed "getting away" with shady practices.
0
u/IamtheHuntress Apr 27 '25
Yet this would be a dream doctors visit to go quickly & move on to the next. This is about greed; it's that simple. Add the fact that doctors' appointments used to be scheduled for 30 minutes, but now they're 15, so of course they're going to run behind, occasionally This is so they can double in patients. Once again, this is greed.
2
u/Max_Snow_98 Apr 27 '25
Yeah those dr’s offices really bank on patients’ copays, good call. Insurance reimbursement is pretty nominal.
2
u/CarlEatsShoes Apr 27 '25
I don’t know a lot of doctors who are living in poverty.
1
u/Max_Snow_98 Apr 27 '25
you do know they can have 6-8, sometimes more years of student loans with minimal earnings, if any? Add delayed family, mental health stress…Some might consider it deserved versus looking at it through a simplistic lens.
0
u/CarlEatsShoes Apr 27 '25
If you think being a doctor is a financial hardship, you should try not being a doctor.
0
1
u/justinwtt Apr 27 '25
this is why people pay for studying billing at school so they can bill anything they could. The practice I used to went, they used to allow parents to call and answer some quick questions like fever less than 39F, no pills needed…. Now, they charge $50 for each phone call.
1
u/Radicalrey Apr 27 '25
Call the insurance and tell them it was part of your history and therefore part of the annual exam. He could have asked “ how’s your high blood pressure?” Etc. Tell them it was not a new problem. If they say they don’t have headaches as a previous condition tell them it’s not your fault what they do or do not document. Call the insurance
1
u/Highstakeshealthcare Apr 27 '25
Yes. Absolutely!!! That’s a trap. When you go for a wellness visit keep your mouth shut. If the doctor asks “how’s things going”, answer “fine”. If the doctor asks if there’s anything that’s been bothering you, answer “nope. Everything’s great”. Don’t show them a bruise on your hand or a pimple on your forehead and don’t let them look at anything not directly related to wellness. Get in and get out as quick as you can.
1
u/hunny_bunny345 Apr 27 '25
First tell your physician that you were incorrectly billed and ask them to resubmit the claim as only a preventative exam. If that doesn’t work, let the insurance company know that no additional services were provided and the provider coded it incorrectly. Ask for a claims review. They should then reach out to the provider and ask them to do a rebill. If nothing changes, you can appeal in writing to the insurance company. They take those seriously and will investigate. The provider could get dropped by the insurance company if they find out they are submitting false claims so the provider does have incentive to correct this.
1
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u/Initial_Warning5245 Apr 27 '25
Anything not preventative is a sick visit on top. All though 1 word seems a stretch. Are you certain no other tests were run?
1
u/LeftDraw5540 Apr 28 '25
I recommend requesting the medical records and appealing with your insurance. Include the medical records and say in your appeal something like- based on the attached medical records does the extent of the diagnostic questions discussed equate to the billing of a medically necessary office visit? Or is this all included in my preventive visit?
1
u/mitchrusschels Apr 28 '25
That's insane. At my annual physicals, I ask multiple questions, and so does the doctor. No extra charges.
1
1
u/guss_bro Apr 28 '25
All the doctors(I go to new one every year and I moved a lot in past 10yrs) that I visited for my annual exam asked if I had any other issues that I want to discuss at least 5 times in the ~15 minutes visit.
1
u/Chels_birder Apr 28 '25
Do you have a separate visit with your doc at least once yearly to talk about your headaches? If not, it’s perfectly reasonable to include that as a chronic health issue they’re treating during an annual, since they prescribe you medication for it.
1
u/Black-EyedSusan96 Apr 28 '25
It is ridiculous that at a WELL visit you cannot ask questions about keeping yourself WELL.
1
1
u/Maker_Freak Apr 28 '25
Question it with the provider as to why there's a charge for that. You cna ask them to send it back through coding. My son had a first visit with a PCP and I mentioned that he has a birthmark next to his eye, and how it hadn't changed since birth. They tried to bill me for an additional office visit, not part of his annual physical which is fully covered. When I talked to the provider (billing department), said how checking the skin is part of a physical, and it's the first visit. They weren't looking at an acute condition, it was part of history. They removed the charge. It was only the $20 copay, but it was the principle.
1
u/Remarkable-World-234 Apr 28 '25
I go to neurologist for Botox for headaches. It’s in conjunction with other meds. When I went for procedure they told me I couldn’t discuss my other medications and needed to book another appointment because that’s “medication maintenance”.
1
u/Upper-Fun-3992 Apr 28 '25
At my last annual they told me they could only address one concern or I’d be billed extra. My concern was hairloss and acne related to hormonal issues and they told me I could either discuss the hair loss or the acne but not both. Even though they were both stemming from the same problem🥲 the system is so flawed.
1
u/justgettingby1 Apr 28 '25
My new strategy for this: I schedule my annual exam (Medicare), and a second exam a week later. At the annual exam, I tell them I do not want to be billed for anything except the annual exam. So it’s on them to not do anything that generates a second exam charge.
At the second exam a week later, we discuss everything anything else.
I was getting really annoyed by being charged for two exams during my 1/2 hour visit. So now, I still pay for two exams, but I get an hour’s worth of advice. Screw their policy of answering “better” and charging me for it.
1
u/BlueLanternKitty Apr 28 '25
Providers are allowed to ask about the state of chronic conditions during a wellness visit. “how are the migraines?” “Fine” would not make it a problem visit. There’s no extra labor or increased patient risk associated with the plan of care for the condition. Things like additional testing, a change in treatment plan, etc.,—stuff that could be an extra visit—is where issues arise.
You are allowed to bill a problem visit and annual physical on the same day, using modified -25. But often, the insurance will pay a reduced rate for the problem E/M code, if they pay it all.
So “asking about chronic conditions” gets reinterpreted as “don’t bring up anything else because that’s work you won’t get paid for doing.”
1
1
u/mmaalex Apr 30 '25
Call and ask. They may have just miscoded, I've had them do that at the "free well visit" and it took months to get resolved, but eventually they fixed it and it was free.
1
u/Local_Historian8805 May 01 '25
Thanks Obama and the affordable care act of 2008. That is what made it unethical for doctors to manage other doctors and now we have MBAs running health care.
Yet a lawyer can manage other lawyers.
Make it make sense.
1
u/genericusername20211 May 01 '25
This also happened to me. I called the billing office and had it escalated for review and they still said I owed them money. They would call every week and mail me a bill every other week. It’s been a year and a half since that visit and they’ve finally quieted down. I don’t know if they gave up or they turned it in to collections.
1
u/DefrockedWizard1 Apr 27 '25
office bills can be based on time or complexity. for higher complexity visits your insurance company will also expect a certain amount of time spent. in the future document the length of time between nurse and physician minus wait time, then you can inquire with your insurance company if it was appropriate. on the surface though, this sounds like padding the bill. I don't know what the magic number of such inquiries is to trigger an investigation, but what they do is either or both, send agents pretending to be patients and do their own documentation, or demand a certain number of specific charts for their covered patients to review while in the dr's office. they are not allowed to remove them from the office, and typically show up unannounced
3
u/Intelligent-Mud7047 Apr 27 '25
Dr was 7 minutes. I didn’t know nurse was considered part of time.
4
u/DefrockedWizard1 Apr 27 '25
unless the nurse was doing more than vitals, that's probably a level 2 visit, maybe at most a 3
3
u/liltingly Apr 27 '25
They probably justified the code as MDM and complexity-based. If OP had a Dx for anything, and doc said they did anything specific to that Dx, it’s no longer a well visit.
A lot are slapping the G2211 modifier if it’s an established patient and a long term diagnosis (at least in specialty).
3
u/Intelligent-Mud7047 Apr 27 '25
I’ve been on same meds for 10/years no changes
1
u/liltingly Apr 27 '25
Yeah. They still upcode because they are “re-evaluating” each time. I’m in the same boat. Sucks, but this is the system by which doctors get paid. Time/complexity based billing, and usually they get only back a % of what they bill per payer, so their incentive is to always bill the highest possible thing assuming it will somehow be reduced.
If you’re OOP you can sometimes play hardball with the billing dept and they’ll lower it. It’s worked some times for me. Or sometimes if you wait long enough either insurance will cave or the hospital and your bill gets reduced magically. That’s only happened a few times to me.
2
1
u/No-Donut-8692 Apr 27 '25
This is allowed. Many offices are quite aggressive about billing for an office visit charge on top of the annual physical fee when a problem is addressed. Typically, they will bill the full charge for a stand-alone office visit. However, insurance will not allow this full amount and it will be knocked down to a much smaller add-on to the payment for an annual physical. Usually the allowed charge would be something closer to $30-$50. Not knowing your deductible/copay, I can’t predict how much of this you would actually have to pay.
1
Apr 27 '25
There’s not enough Information here to know what happened with the coding. It’s a catchy title for the thread and written in a way for lots of gasoline to be thrown on this fire but there’s no substance to the single ambiguous fact presented to know if the premise represents reality
1
u/jewboy916 Apr 27 '25
I've stopped going to my annual "wellness" exam for this exact reason. They fish for reasons to charge you more. If I have a health issue, I'll schedule an appointment then. Annual physicals have become nothing more than a money grabbing scheme.
1
u/IMGYN Apr 27 '25
Im a PCP.
I have signs in every exam room that tells patients the difference between an office visit and a preventative visit. Also if a patient comes for a physical my MA lets them know that anything outside of a routine screening will also including billing as an office visit. This avoids a lot of confusion and patients will usually let me know "hey doc only here for a physical, will Schedule an office visit later." That way I'm not wasting my time and they don't get a surprise bill.
0
u/buzzybody21 Apr 27 '25
Did you have a visit with the doctor?
1
u/Intelligent-Mud7047 Apr 27 '25
Nurse took my blood pressure. Dr checked my heart, lungs. Asked me if I go to ear dr and then asked me about my headache which I replied better. That was it.
-2
u/buzzybody21 Apr 27 '25
Because you had a visit and an exam, they can charge you for $200.
11
2
u/glitteringdreamer Apr 27 '25
There is no charge for annual exams.
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u/buzzybody21 Apr 27 '25
For some plans. Not all plans fully cover annual exams, including mine. I still have a copay and am responsible for any related bloodwork, even if it is considered routine.
2
u/mrpickle123 Apr 27 '25
Any ACA-compliant policy is required to provide preventive visits free of charge. Insurance companies don't decide that, the federal government does. If your policy has exclusions for that, it is likely not ACA compliant.
1
u/buzzybody21 Apr 27 '25
My plan is ACA compliant and provided by my employer. I am required to pay a copay. Maybe because of the labwork.
1
u/mrpickle123 Apr 27 '25
I like to use UHC's provider-side document for these q's because it's easy to find on google. This is a full list of codes that are considered preventive and their requirements. It's not specific to UHC, this is just a coding aid based off of those requirements for their contracted providers to review and confirm benefits.
If you can get a hold of a claim and get the actual procedure codes off your claim, Ctrl+f through this document and you will probably be able to determine what is causing the visit/service to be processed as diagnostic rather than routine. ACA compliant plans legally HAVE to cover these services for any fully insured (read: 50 employees or more) commercial policy for any qualified patient/member.
0
u/BaxterBites Apr 27 '25
annual physical are usually are at no cost
5
u/Intelligent-Mud7047 Apr 27 '25
This was on top of office visit. My annual, preventative visit is 30%. I have a self insured health plan so they state this is allowed.
0
u/Jacjim Apr 27 '25
Went to the doctor, had three acute problems going on. Was told by doctor in training that I could only talk about one problem, I asked which one she wanted to treat after telling her all the problems. I wish I could find a wholistic doctor who would treat all my medical issues. If you don’t advocate for yourself, you’re dead.
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